| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
131 |
78 |
$26K |
| D1120 |
Prophylaxis - child |
269 |
245 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
381 |
348 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
109 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
221 |
$6K |
| D1351 |
Sealant - per tooth |
76 |
43 |
$6K |
| D0274 |
Bitewings - four radiographic images |
279 |
256 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
86 |
$4K |
| D1110 |
Prophylaxis - adult |
89 |
87 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
150 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
377 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
367 |
338 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$338.70 |
| D0272 |
Bitewings - two radiographic images |
32 |
28 |
$263.20 |